Abstract

Background: In the context that special weaning units
have been advocated as effective alternatives to the ICU for weaning
selected patients, we initiated a Respiratory Special Care Unit (ReSCU)
at the Cleveland Clinic Hospital in August 1993. The goals of the ReSCU
were the following: (1) to wean ventilator-dependent patients when
possible; and (2) when weaning was not possible, to optimize patient
and family instruction for patients going home with ventilatory
support. This study presents our 4-year experience with 212 patients
managed in the ReSCU and analyzes clinical features associated with
favorable clinical outcomes.

Methods: The features of
the ReSCU include six private beds in a pulmonary inpatient ward
staffed by nurses with special pulmonary expertise; 24-h respiratory
therapy supervision; bedside and central noninvasive monitoring
(ie, continuous pulse oximetry, end tidal capnometry,
and ventilator alarms); and a multidisciplinary approach involving
dietitians, physical therapists, occupational therapists, social
workers, and speech pathologists. All ReSCU patients were cared for
primarily by a pulmonary/critical care attending physician and fellow,
with consultative input solicited as deemed necessary. The criteria for
admission to the ReSCU included hemodynamic stability; absence of an
arrhythmia requiring telemetry; and in the attending physician’s
judgment, the ability to benefit from the ReSCU.

Results: Between August 23, 1993, and August 31, 1997, 212
patients were admitted to the ReSCU. The median age was 68 years old;
55% were women; 86% were white; and 55% were transferred from the
medical ICU. Underlying reasons for ventilator dependence were ARDS
from a nonsurgical cause (33%), ARDS following surgery (18%), status
post-cardiothoracic surgery (13%), status post-thoracic surgery
(12%), and COPD (12%). The median length of ReSCU stay was 17 days
(interquartile range, 10 to 29 days). Eighteen percent (n = 38) died
during the hospitalization. Among the 174 survivors, complete
ventilator independence was achieved in 127 patients (60% of the 212
patient cohort), 28 patients were ventilator dependent (13% of 212
patients), and the remaining 19 patients (9%) required partial
ventilatory support. Univariate analysis regarding the association of
baseline characteristics with death identified lower albumin and
transferrin levels, increasing age, and the physician’s estimate of
lower weaning likelihood as significant correlates of death. In
contrast, achieving complete ventilator independence was associated
with a higher serum albumin level, a nonmedical ICU referral source, a
cause of respiratory failure other than COPD, and a physician’s
estimate of higher weaning likelihood. To analyze the financial impact
of the ReSCU, we assumed that ReSCU patients would have otherwise
stayed in the medical ICU and compared the charges (ICU vs ReSCU) with,
for a subset of patients, the true costs of ReSCU vs ICU care. Analyses
of both charges and cost differences showed similar savings associated
with ReSCU care ($13,339 per patient [charges] and $10,694 per
patient [costs]).

Conclusions: We conclude the
following: (1) the rate of achieving complete ventilator independence
in the ReSCU was high; and (2) based on our achieving clinical
outcomes, which are comparable to the most favorable rates
reported in other series from ventilator units, we conclude that the
ReSCU can be an effective and cost-saving alternative to the ICU for
carefully selected patients.

Return to: Four-Year Experience With a Unit for Long-term Ventilation (Respiratory Special Care Unit) at the Cleveland Clinic Foundation*

Copyright in the material you requested is held by the American College of Chest Physicians (unless otherwise noted).
This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material
solely for personal, non-commercial use, and that it is subject to the American College of Chest Physicians’ Terms of Use.
The information provided in order to email this topic will not be used to send unsolicited email, nor will it be
furnished to third parties. Please refer to the American College of Chest Physicians’ Privacy Policy for further information.

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username
(required)

Email Address
(required)

Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.